Hemophilia Case Review Form — Coverage / Authorization Intake
This document is a Hemophilia Case Review Form used by providers and specialty pharmacies to request and document factor products, dosing, bleeding events, and dispensing details for members; it governs submission of information to the payer’s case review/authorization process.
No material clinical or coverage changes in this revision.
Coverage Criteria Summary
This document is an intake-style Hemophilia Case Review Form used to collect clinical and prescription details needed for case review and potential authorization. It does not itself define coverage criteria or exclusion rules; rather, it captures information such as product name, dosing instructions, number of doses/units requested, dates covered, treatment status, type of use (e.g., episodic, prophylaxis, acute bleeding episode, procedural prophylaxis), and place of administration to support the payer’s review.
The form does not list explicit not medically necessary conditions or formal exclusion language. Its scope is documentation and authorization intake: providers must complete the form in its entirety and submit supporting materials (for example, progress notes or bleeding diaries) to the payer for review rather than relying on the form to communicate covered versus non-covered services.
Provider Actions and Submission Requirements
Form completion and submission requirement
Complete the Hemophilia Case Review Form in its entirety and submit it with all required supporting documentation. The form must include dosing information (dose in IU), number of doses/units requested, total dose requested (IU), indication/type of use (episodic, prophylaxis, acute bleed, dental or surgical prophylaxis), dates/days' supply, place of administration, and any sig or special instructions. Fax completed form and attachments to 1-888-656-0841 or call 1-800-424-7892 for assistance.
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